Intake FormThank you for filling out the form before our first session; this will help me support you. Reach out if you have any questions. 719-623-5884 Name * First Name Last Name DOB * AGE * Pronouns * Ethnicity * African-American Asian Caucasian Hispanic/Latin Native American Multiethnic Other Do not wish to disclose Email * Okay to send correspondence? * Yes No Phone * (###) ### #### Okay to leave voicemail * Yes No Okay to leave a text message? * Yes No Address * Why are you seeking counseling? * Anger Self-esteem Anxiety Life Transitions General Growth Stress Trauma Depression PTSD Communication Cultural Conflicts Emergency Contact Name * Emergency Contact Phone Number * Are you employed? * Full Time Part Time Unemployed Occupation/Place of work Education Level * 6th 7th 8th 9th 10th 11th 12th Some College Associates Bachelors Masters PhD Trade School Marital Status * Single In relationship Married Separated Divorced Do you have children? * Yes No If yes, Children names and ages Do they live with you? Full time Part time No Are you on any medication? * Yes No If yes, Medications/Dosage/Frequency taken What is the general condition of your health? * Physician's Name/Number PLease describe your physical and mental health including significant hospitalizations, illnesses Are you currently receiving other mental health services or medical treatment? Have you ever given serious consideration to, or attempted to , end your own life? * Yes No If yes, date of last occurrence-please describe: Have you ever given serious consideration to, or attempted to harm another person: * Yes No If yes, last occurrence: Is there a history in your family of any of the following? check all that apply Sexual Abuse Emotional Abuse Alcoholism/Drugs Sleep Disorder Eating Disorder Physical Disability Conditions Physical Abuse Rape Violence Which of the following areas have been or are a problem for you? Check all that apply Marriage/Partner Job/School Finances Smoking Sexual Difficulties Friendships Family Distance from loved ones Depression Alcohol/Drugs Spirituality Legal Mood Eating Habits Anger Experienced discrimination Health problems Death/Major Loss Caffeine Ability to control Anger Sleeping Anxiety/Fear Loneliness Gender Identity Conflict Repetitive Behavior Financial concerns Work/School problems Do you currently use tobacco, alcohol, or other drugs? * Yes No Please list substances used currently or in the past, how much and how often? Past substance abuse treatment? * Yes No Are you involved in the legal system or have you had significant legal issues in the past? * Yes No Please give me a brief family history. Describe family of origin and your current family dynamics What brings you to seek therapy now and what do you hope to gain? * Is there anything I have not asked you that is important for me to know? What are your concerns about therapy? Have you receive counseling before? * Yes No How did you hear about us? * Return client medical professional friend or family member mental health care professional crisis line online search Sparking Hope Therapy website Thank you!
